1. Christian Monsalud
Professor Jamie McDonald
HSC 421: MoWe 8-9:15AM
April 17, 2013
Health Program Review
Sexual activity among teenagers is one of the major health problems in the United States
today. With the lack of comprehensive sex education programs in schools, children as young as
11-12 years old in the sixth grade are beginning to experiment with sexual intercourse. As a
result, the school-age population is at higher risk for unwanted pregnancies and early exposure to
sexually transmitted infections (STI) and HIV as well as other risky behaviors including oral and
anal intercourse. Due to the strict implementation of abstinence-only sex education programs at
the school site level, young adolescents have limited knowledge and access to resources that can
protect themselves from these highly preventable disparities. The need for comprehensive sex
education programs is especially crucial for the healthy development of young adolescents as
they reach puberty and are experiencing a manifold of psychological and biological changes.
To delay sexual behavior among teenagers, the goal of the It’s Your Game: Keep It Real
(IYG) program is to decrease the amount of young adolescents engaging in sexual intercourse
before they reach 9th grade. This program also focuses on HIV, STI, and pregnancy prevention
among the youth population. The target population for IYG is middle school students in the 7th
and 8th grade. IYG was first implemented in English-speaking middle schools in the
Southeastern portion of Texas. These students derive from families with low socioeconomic
status and reside in large, urban neighborhoods. A majority of these students are also of African
American and Hispanic descent. This target population was specifically chosen for its
disproportionately high rates of HIV and STIs in these ethnic groups.
Three health behavior theories applied to this intervention include the social cognitive
theory, social influence models, and the theory of triadic influence (Tortolero et al., 2013).
Originated by Albert Bandura, the social cognitive theory aims to change behavior through the

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evaluation of individual characteristics and environmental factors. According to Positive Action
(2013), the theory of triadic influence is a meta-theoretical framework that observes how three
streams of influence affect the seven causes of behavior change. The three streams of influence
include the effect of the socio-cultural environment on attitudes toward the behavior, the effect
of social context/situations on social normative beliefs, and the effect of intrapersonal factors on
self-efficacy and behavior control. The causes of behavior change include social support and
bonding processes, proximal cognitive predicts of behavior, focus on expectancy-value
formulations, social learning processes, and personality and intrapersonal processes. The theory
of triadic influence also observes how inter-stream effects have direct and indirect effects on
behavior. These inter-stream effects include external factors such as health and drug information,
feelings, empathy, communication skills, self-concept, and conflict resolution. Feedback loops
between these inter-streams and causes of behavior change explain the adoption of new
behaviors and the maintenance of regular behaviors (“Positive Action,” 2013). Examination of
the relationships between these complex webs of influences provides a more comprehensive
understanding of health behavior change. The social influence models also examine how an
individual’s social network affects behavior change through complex communication strategies
and interactions with different subgroups to produce new ways of thinking and attitudes.
IYG’s intervention methodology is unique because it utilizes multi-modal components to
enhance the quality of comprehensive sex education programs and increase additional access to
resources. IYG combines traditional methods of instructional lecture with group-based classroom
activities, computer-based instruction, writing skills, and parent-child interaction. To estimate the
success of the program, the intervention program and a comparison condition which was a
regular health education class were randomly assigned to ten middle schools in Southeast Texas.

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In the intervention program, twelve lessons were presented to 7th and 8th graders. Each lesson
consisted of a 45 minute traditional lecture presented by a health educator or a trained facilitator.
In addition to each lecture, the other components of the technology-based activities were also
implemented. Group activities involved student interaction to enhance and build social networks
with diverse populations. This allows for each social network to identify their characteristics and
to present their own personal opinions and ideas to promote vicarious learning, reinforcement of
positive behaviors, and reciprocal determinism. Computer-based instruction involved individual
activities on personal laptops. Activities include role playing of different characters in specific
scenarios using virtual reality, quizzes, video animation, examination of electronic fact sheets
and other organized information, peer review of assignments, and online group discussions.
Computer-based technology for individual activities helps develop an individual’s sense of self-
efficacy, behavioral capacity, and self-control when encountering sexual risk-taking scenarios
without experiencing the negative consequences in reality. The students are also assigned with
the task of developing personal journals by using their creative writing skills to express opinions,
feelings, and thoughts about sensitive sexual issues. This method is beneficial in assisting
students with their emotional coping skills associated with behavior change and creating
expectations. Due to the confidentiality of the assignment, the students have the freedom of
expression in contrast to the strict abstinence-only education programs. In this assignment, their
ideas and thoughts are highly valued which is important in psychological development. IYG also
teaches students how to make responsible decisions through a life skills management process
called Select, Detect, Protect. First, they must select behaviors that are considered risky and
dangerous such as sexual intercourse and set personal goals to delay or limit the occurrence of
these behaviors. Next, they must detect factors that would tempt students to engage in this risky

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behavior and implement various strategies to protect their new behaviors. A final component of
the intervention includes assignments that involve parent-child interaction by discussing topics
such as friendship qualities, dating, and sexual behavior. Parent involvement is essential in
reinforcing positive attitudes as well as enhancing healthy sexual behaviors through vicarious
learning and reciprocal determinism. As a result, students and their parents are able to develop
trust for another. In addition, it also helps parents communicate with their child about sexual
issues which is a very sensitive and often embarrassing topic to discuss. Furthermore, each grade
has a set of sexual health issues that are appropriate for different maturity levels. Examples of
topics discussed at the 7th grade level include healthy friendships, setting personal health goals,
practicing refusal techniques, and information about puberty, reproduction, and STIs. Topics
discussed at the 8th grade level include conditions for healthy dating, highlighting the beneficial
reasons and identifying sources for HIV, STI, and pregnancy testing, developing motor skills for
putting on condoms, and information about contraceptive methods. All in all, IYG utilizes a
variety of educational components to provide a unique and comprehensive learning experience
(Tortolero et al., 2013).
Results of the intervention were evaluated with data acquired through follow-up surveys
from the intervention participants when they reached 9th grade. Overall, the intervention was a
success. According to the study conducted by Tortolero et al. (2013), 30% of the students in the
comparison group who received regular health education classes engaged in sexual intercourse
by 9th grade. On the contrary, 23% of the intervention participants reported sexual activity by the
9th grade. Thus, the intervention group was less likely to engage in sex while the comparison
group was more sexually active. Additionally, there were higher rates of oral, vaginal, and anal
sexual activity in the comparison group compared to the intervention group. African American

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and Hispanic students in the intervention group were also less likely to engage in sexual
intercourse. The students in the intervention group had more positive attitudes about abstinence,
greater confidence and skill in utilizing the refusal technique and generally greater knowledge
about the benefits of using condoms. In addition, the IYG group had substantially greater
knowledge about HIV and STIs, were able to justify their reasons from abstaining from sex and
had greater intention to remain abstinent throughout high school. As a result, the intervention
group engaged in fewer sexual activities. The IYG intervention is an effective health program
because the current generation of the youth population is moving towards a technology-based
lifestyle. As a result, the students are more engaged in the learning process through hands-on
activities and stimulating visual aids with laptops and computers.
Although IYG is an effective program for teaching teenagers about sexual health, the
program still has barriers and challenges to overcome. First of all, the article studied the results
of this intervention program only in populations with low socioeconomic statuses and
disregarded its effectiveness in the middle and upper class societies. The curriculum of the
intervention program also needs to put more emphasis and focus on specific cultural factors that
determine sexual behaviors. Another challenge is that since this intervention utilizes expensive
computer technology, it might be difficult to implement this program in schools where the
majority of the population has low socioeconomic statuses and funding from the school is
limited. Also, some of the topics discussed in the curriculum might be too controversial in areas
that favor abstinence-only education and controlled by religious groups. Since this intervention is
applied only at the school site level, it could be difficult to influence a behavioral change in
students who drop out of school, are truant, or move around during the middle of the semester.

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References
Positive Action. (2013). Theory of Triadic Influence. Retrieved from
http://www.positiveaction.net/research/index.asp?ID1=3&ID2=67&ID3=221
Tortolero, S. R., Markham, C. M., Peskin, M. F., Shegog, R., Addy, R. C., Escobar-Chaves, S.
L., & Baumler, E. R. (2010). It's Your Game: Keep It Real: Delaying Sexual Behavior
with an Effective Middle School Program. Journal of Adolescent Health, 46, 169-179.
doi: 10.1016/j.jadohealth.2009.06.008